Provider Demographics
NPI:1598778920
Name:RYSWYK, GLEN W (MDIV LPC LMFT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:W
Last Name:RYSWYK
Suffix:
Gender:M
Credentials:MDIV LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8320
Mailing Address - Country:US
Mailing Address - Phone:580-531-4512
Mailing Address - Fax:580-531-4519
Practice Address - Street 1:5002 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-8320
Practice Address - Country:US
Practice Address - Phone:580-531-4512
Practice Address - Fax:580-531-4519
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK577101YM0800X
OK717106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist